Program Purpose PERFORMANCE PLAN ADSD Amy Vennett x1714 Program Information Improve and then maintain the health status of adults with multiple chronic illnesses and/or disabilities so they successfully age in place at home Program serves Arlington residents 60 years old or older with multiple chronic illnesses or adults age 18 to 59 with a permanent disability who require assistance managing health care needs and lack a sufficient support system. A community physician is required to order case management services. Brief client profile: More than take more than seven medications; more than 70% live alone; 75% have a psychiatric diagnosis; 25% have some form of dementia Core services provided in client homes 1 to 4 times per month include: o Initiating and updating care plans focused on individual needs o Assessing and monitoring health status and care needs o Educating clients about health and wellness needs o Pre-pouring medications if pharmacy bubble-packing is not available o Referring to and coordinating with other providers and services Additional services include: o Screening for nursing home level services to include placement and community based care o Assessing clients for in-home services This is the only program of its kind in Virginia and is 100% locally funded PM1: How much did we do? Staff Total 5.25 FTEs: o 0.75 FTE Supervisor o 4.5 FTE Nurses (88% of 6 FTEs) Customers Units of Service Total NCM Clients Served 302 303 446 Ongoing Services Clients 140 123 103 Clients receiving NCM intake assessments or consultations 50 49 180 Clients screened for nursing home level care 112 131 163 New Ongoing Services Clients 28 24 22 Ongoing NCM Client Visits 3,261 2,968 2,840 PM2: How well did we do it? 2.1 Caseload size 2.2 Care plans initiated and updated quarterly PM3: Is anyone better off? 3.1 Clients who have improved or maintained their health status in the last year: blood pressure, medication adherence and emergency room (ER) visits Page 1
Number of Clients PERFORMANCE PLAN Measure 2.1 Caseload size 30 Monthly Average Workload 25 20 2 1 2 1 3 3 Target caseload: 25 2 1 15 10 24 21 21 25 5 0 27 clients 24 clients 27 clients Ongoing Caseload Assessments Screenings FY 2017 (proj) 28 clients The workload ratio for on-going clients, as well as assessments and prescreenings, are both presented. The average ongoing caseload in was 21 with 3 assessments and 3 screenings on average per nurse each month. The average workloads are calculated by averaging the end-of-month censuses from across the year. Monthly average on-going caseload per nurse did not increase as forecasted. However, the total workload of all clients served (including assessments and pre-screenings) increased to 27 in. Workload and productivity measures research was placed on hold due to staff leave and focus on other nursing needs in the division. In, 0.5 FTE of one nurse began conducting assessments for in-home services to allow greater depth for this task in the division and outreach to more potential NCM clients. More clients were touched by NCM but not necessarily identified as needing on-going NCM services but received short term consultation or were referred to other programs and services. Continue to implement efficiencies and analyze program for additional improvements. Program will research workload, acuity and productivity measures in FY 2017 with the goal of identifying a measure that better represents the depth of the workload of staff. Manager will monitor caseloads on a monthly basis of nurse case managers. FY 2017: Workload size will average 28; on-going caseload will average 25. Page 2
Percent of Care Plans Percent of Care Plans PERFORMANCE PLAN Measure 2.2 Care plans initiated with 10 days and updated quarterly 100% Care Plans Initiated Within 10 Business Days 100% 100% 100% Target: 95% 95% 60% 40% 0% 28/28 Charts 24/24 Charts 22/22 Charts 24/25 Charts Care Plans Updated Quarterly 100% Target: 100% 100% 98% 95% 95% 60% 40% 73/73 Charts 70/70 Charts 63/64 Charts 61/64 Charts 100% of charts had care plans initiated within 10 days of admission. Manager reviews all new charts to determine if care plans were initiated within 10 business days. 98% of charts reviewed had care plans updated quarterly. Manager reviews a random sample of 20-25% of active cases each quarter. Care plans were consistently initiated within 10 days of case opening. Quarterly compliance has been maintained. Manager will continue to monitor the initial and ongoing care plans to ensure this measure continues to be achieved. FY 2017: Rate of compliance will be at least 95% for both initiating new care plans within 10 days and updating care plans quarterly. Page 3
Percent of Clients Measure 3.1a 100% 90% PERFORMANCE PLAN Clients who have improved or maintained their health status in the last year: Blood pressure for clients with high blood pressure diagnosis Clients Within and Outside Normal Limits for Blood Pressure: Quarterly Average 9% 9% 4% Target: 90% 10% 70% 60% 50% 40% 91% 91% 96% 90% 30% 10% 0% 78/86 Clients 68/74 Clients Clients Within Normal Limit 68/71 Clients 72/80 Clients Clients Outside Normal Limit Clients within normal limit have blood pressure within norm for at least of visits during the quarter. The number of clients within normal limits is then averaged each quarter to get an annual average. 69% (71/103) of NCM clients have a diagnosis of high blood pressure. For these clients, data was collected at each visit and pulled into a report each quarter, using the electronic documentation system. In, an average of 96% of clients with a diagnosis of high blood pressure were within normal limits each quarter. This is a slight improvement from the last two fiscal years. The percentage of NCM clients with blood pressure within normal limits is significantly higher than a national survey that indicated 50% of older adults with a high blood pressure diagnosis had blood pressure within normal limits (CDC Vital Signs 2016). NCM intervention is effective in helping people manage blood pressure. Nurses will continue to monitor blood pressure at each visit and report findings. Nurses will continue to educate clients on healthy activities and diets that can lead to improvements in blood pressure. Page 4
PERFORMANCE PLAN The national standard for normal blood pressure (Eighth Joint National Committee) is of the time blood pressure is: o 150/90 or less for clients over 60 o less than 140/90 for those under 60 o less than 140/90 for clients (all ages) with diabetes or chronic kidney disease FY 2017: At least 90% of clients with high BP will maintain blood pressure within normal limits. Page 5
Percent of Clients PERFORMANCE PLAN Measure 3.1b 100.0% 90.0% 80.0% 70.0% 60.0% Clients who have improved or maintained their health status in the last year: Medication adherence for clients who have medication pre-poured or bubble-packed Client Adherence to Medication Regimen: Quarterly Average 3.0% 3.0% 1.0% 3.0% 22.0% 20.0% 9.0% Target for 90.0% full/ partial 22.0% adherence: 95% 75.0% 77.0% 75.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 66 Clients 51 Clients 37 Clients 40 Clients Fully Adherent Partially Adherent Nonadherent 90% of clients for whom nurses monitored pharmacy bubble-packed medications, pre-poured medications into a pill box, or pre-filled insulin syringes fully adhered to medication regimen as prescribed. Total of 99% had partial or full adherence. An average of 37 clients per quarter had medications monitored or pre-poured by nurses. was recorded at each visit and pulled into a report each quarter using the electronic documentation system. Nurses reported if clients were adherent partially adherent or non-adherent at each visit. Quarterly and annual averages were calculated. Nurses evaluate medication adherence based on a 2005 New England Journal of Medicine article: to 100% of medications taken is adherent; 50% to 79% is partially adherent; below 50% is not adherent. Percent of NCM clients fully or partially adherent to medication regimen exceeds a national study indicating 68% of adults NCM intervention is effective in helping people manage adherence to medications. Page 6
fully or partially adhered to treatment regimens (2013 US National Report Card on Adherence) Partnered with local pharmacies to place medications in a bubble-pack to improve the nurses ability to assess medication. Fewer clients reported as served in FY 2016 because some nurses stopped collecting data for clients with bubblepack intervention early in the year. PERFORMANCE PLAN Nurses will continue to use pharmacies that can bubble-pack medication, pre-pour if bubblepacking is not available, and monitor medication adherence. Continue to monitor all clients who have a nursing intervention aimed at improving adherence whether the nurse is pre-pouring the medication or the pharmacy is bubble-packing medication. Clarify data collection parameters with staff when changes occur and periodically throughout the year. FY 2017: At least 95% of clients for whom the nurse monitors pharmacy bubble packs, pre-pours medication, or pre-fills insulin syringes will demonstrate full or partial adherence. Page 7
PERFORMANCE PLAN Measure 3.1c 100% 90% 70% 60% 50% 40% 30% 10% 0% Clients who have maintained or improved their health status in the last year: Decreased client ER visits Emergency Room Visits for New Clients who had Visits Before Admission 38.5% 23% 38.5% 26 Clients 25% 75% 8 Clients 10 Clients Fewer visits Same number of visits More visits Target > 60% 10% 70% 15 Clients : Ten clients (45% of new clients) had unplanned emergency room (ER) visits in the three months prior to admission. o (8) of these clients had fewer unplanned visits in each of the first four quarters of being served. This is a slight increase over. o No clients had more visits than noted prior to admission. ER visits are recorded based on self-reports of clients, family members, caregivers and referrers. Staff records the number of admissions in the quarter prior to admission and during the first four quarters of service. Exceeded goal: percent of new clients had fewer ER visits. Sample size was small. Few clients had ER visits reported prior to admission to program. Client factors such as falls, unstable physical or mental health conditions, and client preferences contribute to unplanned emergency room use. Research on an alternative measure for future use was not conducted in in favor of pursuing potential measures related to staff productivity. Program will continue to emphasize client education about alternatives to ER use. FY 2017: 60% of clients with unplanned emergency room visits prior to admission will have fewer unplanned visits. Page 8